eMedicine Specialties > Ophthalmology > Neurologic Disorders

Trigeminal Neuralgia: Follow-up

Author: Marc E Lenaerts, MD, FAHS, Staff Neurologist, Mercy Medical Group, Sacramento, CA; Associate Clinical Professor of Neurology, Department of Neurology, University of California at Davis, Sacramento
Contributor Information and Disclosures

Updated: Jan 29, 2010

Follow-up

Further Inpatient Care

  • Except for surgical procedures, trigeminal neuralgia is not an affliction to treat on an inpatient basis.

Further Outpatient Care

  • Longitudinal follow-up care is important because of the chronicity of trigeminal neuralgia and because many treatments fail to maintain their efficacy (eg, pharmacologic, procedural).
  • Monitor trigeminal neuralgia treatment for adverse effects. Monitoring of blood levels is advised in the case of carbamazepine or phenytoin (ie, monthly for at least 3 mo for carbamazepine, once after 2 wk for phenytoin) and every time the dose is adjusted or adverse effects appear.
  • In the case of carbamazepine, a CBC count should be performed every month for 3 months to rule out bone marrow suppression.
  • Monitoring patients after procedures or open skull surgery helps screen for complications such as corneal abrasions and anesthesia dolorosa.
  • Transcranial magnetic stimulation appears promising, but results are still scarce.26

Deterrence/Prevention

  • Percutaneous procedures and surgery yield the best results when applied early in the course of trigeminal neuralgia. Even if medical treatment comes first, trials, when they are adequately completed and the agent is deemed ineffective, should be followed promptly by the next trial in order not to delay and decrease the efficacy of more invasive treatments.
  • No specific preventative therapy exists. Patients may have a premonitory atypical pain for months; therefore, appropriate recognition of this pre–trigeminal neuralgia syndrome may lead to earlier and more efficient treatment.

Complications

  • A partial destruction of the nerve due to procedures and, sometimes, surgery, can result in anesthesia dolorosa, a condition in which pain is still present but sensation is decreased. Whether pain is or is not present, the decreased pain perception can lead to lesions that remain unnoticed to the patient.
  • Corneal ulceration can result because of trophic disturbances from nerve deafferentation. Therefore, assessing the integrity of facial sensation immediately before and after a procedure, as well as in the long term, is paramount.
  • After any invasive treatments, reactivation of a herpes simplex infection is not uncommon.

Prognosis

  • Idiopathic trigeminal neuralgia is a chronic affliction and needs constant follow-up care; however, its disease course does not progressively worsen.

Patient Education

  • Patients should be aware of potential adverse effects. They should report any altered sensation in the face, especially after a procedure.
  • Patients should be educated about the importance of being compliant with their medication regimen. They should be informed about the potential for anesthesia dolorosa.
  • Patients should be informed that carbamazepine is not prescribed (at this time) for a seizure disorder.
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education articles Trigeminal Neuralgia (Facial Nerve Pain) and Tic Douloureux.

Miscellaneous

Medicolegal Pitfalls

  • Neoplastic infiltration of the nerve should not be overlooked. A case of lymphoma revealed by trigeminal neuralgia has been seen.
  • Failure to diagnose a brainstem tumor and bone marrow aplasia as an idiosyncratic adverse effect of carbamazepine are common pitfalls to avoid. Standard care must be applied to invasive procedures, which are most subject to potential claims.

Special Concerns

  • Anesthesia dolorosa should be a main special concern.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, James Couch, MD, to the development and writing of this article.



More on Trigeminal Neuralgia

Overview: Trigeminal Neuralgia
Differential Diagnoses & Workup: Trigeminal Neuralgia
Treatment & Medication: Trigeminal Neuralgia
Follow-up: Trigeminal Neuralgia
Multimedia: Trigeminal Neuralgia
References
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References

  1. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160. [Medline].

  2. Hess B, Oberndorfer S, Urbanits S, Lahrmann H, Horvath-Mechtler B, Grisold W. Trigeminal neuralgia in two patients with glioblastoma. Headache. Oct 2005;45(9):1267-70. [Medline].

  3. Al-Din AS, Mir R, Davey R, Lily O, Ghaus N. Trigeminal cephalgias and facial pain syndromes associated with autonomic dysfunction. Cephalalgia. Aug 2005;25(8):605-11. [Medline].

  4. Vincent M. SUNCT, lacrimation, and trigeminal neuralgia. Cephalalgia. Mar 1998;18(2):71. [Medline].

  5. Majoie CB, Hulsmans FJ, Castelijns JA, et al. Symptoms and signs related to the trigeminal nerve: diagnostic yield of MR imaging. Radiology. Nov 1998;209(2):557-62. [Medline].

  6. Tanaka T, Morimoto Y, Shiiba S, et al. Utility of magnetic resonance cisternography using three-dimensional fast asymmetric spin-echo sequences with multiplanar reconstruction: the evaluation of sites of neurovascular compression of the trigeminal nerve. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Aug 2005;100(2):215-25. [Medline].

  7. Cruccu G, Biasiotta A, Galeotti F, Iannetti GD, Truini A, Gronseth G. Diagnostic accuracy of trigeminal reflex testing in trigeminal neuralgia. Neurology. Jan 10 2006;66(1):139-41. [Medline].

  8. Campbell FG, Graham JG, Zilkha KJ. Clinical trial of carbamazepine in trigeminal neuralgia. J Neurol Neurosurg Psychiatry. 1966;29:265-267.

  9. Rockliff BW, Davis EH. Controlled sequential trials of carbamazepine in trigeminal neuralgia. Arch Neurol. Aug 1966;15(2):129-36. [Medline].

  10. Beydoun A. Safety and efficacy of oxcarbazepine: results of randomized, double-blind trials. Pharmacotherapy. Aug 2000;20(8 Pt 2):152S-158S. [Medline].

  11. Zakrzewska JM, Chaudhry Z, Nurmikko TJ, Patton DW, Mullens EL. Lamotrigine (lamictal) in refractory trigeminal neuralgia: results from a double-blind placebo controlled crossover trial. Pain. Nov 1997;73(2):223-30. [Medline].

  12. Baker KA, Taylor JW, Lilly GE. Treatment of trigeminal neuralgia: use of baclofen in combination with carbamazepine. Clin Pharm. Jan-Feb 1985;4(1):93-6. [Medline].

  13. Fromm GH, Terrence CF, Chattha AS. Baclofen in the treatment of trigeminal neuralgia: double-blind study and long-term follow-up. Ann Neurol. Mar 1984;15(3):240-4. [Medline].

  14. Khan OA. Gabapentin relieves trigeminal neuralgia in multiple sclerosis patients. Neurology. Aug 1998;51(2):611-4. [Medline].

  15. Tatli M, Satici O, Kanpolat Y, Sindou M. Various surgical modalities for trigeminal neuralgia: literature study of respective long-term outcomes. Acta Neurochir (Wien). Mar 2008;150(3):243-55. [Medline].

  16. Olson S, Atkinson L, Weidmann M. Microvascular decompression for trigeminal neuralgia: recurrences and complications. J Clin Neurosci. Sep 2005;12(7):787-9. [Medline].

  17. Pollock BE, Ecker RD. A prospective cost-effectiveness study of trigeminal neuralgia surgery. Clin J Pain. Jul-Aug 2005;21(4):317-22. [Medline].

  18. Deinsberger R, Tidstrand J. Linac radiosurgery as a tool in neurosurgery. Neurosurg Rev. Apr 2005;28(2):79-88; discussion 89-90, 91. [Medline].

  19. Kondziolka D, Perez B, Flickinger JC, Habeck M, Lunsford LD. Gamma knife radiosurgery for trigeminal neuralgia: results and expectations. Arch Neurol. Dec 1998;55(12):1524-9. [Medline].

  20. Brabant S, Van Zundert J, Van Buyten JP. Proceedings of the World Pain Congress. In: Pulsed radiofrequency treatment of the gasserian ganglion in patients with essential trigeminus neuralgia: A retrospective study. San Francisco, CA: 2000.

  21. Browne L. Radiofrequency lesioning of the trigeminal ganglion for the treatment of trigeminal neuralgia. Ir Med J. Mar 1985;78(3):68-71. [Medline].

  22. [Guideline] International RadioSurgery Association. Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. National Guideline Clearinghouse. Jan 2009.

  23. [Guideline] Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. Oct 7 2008;71(15):1183-90. [Medline].

  24. Kondziolka D, Lemley T, Kestle JR, Lunsford LD, Fromm GH, Jannetta PJ. The effect of single-application topical ophthalmic anesthesia in patients with trigeminal neuralgia. A randomized double-blind placebo-controlled trial. J Neurosurg. Jun 1994;80(6):993-7. [Medline].

  25. Türk U, Ilhan S, Alp R, Sur H. Botulinum toxin and intractable trigeminal neuralgia. Clin Neuropharmacol. Jul-Aug 2005;28(4):161-2. [Medline].

  26. [Best Evidence] Khedr EM, Kotb H, Kamel NF, Ahmed MA, Sadek R, Rothwell JC. Longlasting antalgic effects of daily sessions of repetitive transcranial magnetic stimulation in central and peripheral neuropathic pain. J Neurol Neurosurg Psychiatry. Jun 2005;76(6):833-8. [Medline].

  27. Blom S. Trigeminal neuralgia: Its treatment with a new anticonvulsant drug. Lancet. 1962;1:839-40.

  28. Dalessio DJ. Diagnosis and treatment of cranial neuralgias. Med Clin North Am. May 1991;75(3):605-15. [Medline].

  29. Dubner R, Sharav Y, Gracely RH, Price DD. Idiopathic trigeminal neuralgia: sensory features and pain mechanisms. Pain. Oct 1987;31(1):23-33. [Medline].

  30. Eide PK, Rabben T. Trigeminal neuropathic pain: pathophysiological mechanisms examined by quantitative assessment of abnormal pain and sensory perception. Neurosurgery. Nov 1998;43(5):1103-10. [Medline].

  31. Evans RW, Graff-Radford SB, Bassiur JP. Pretrigeminal neuralgia. Headache. Mar 2005;45(3):242-4. [Medline].

  32. Fromm GH. Pathophysiology of trigeminal neuralgia. In: Fromm G, Sessle B, eds. Trigeminal Neuralgia: Current Concepts Regarding Pathogenesis and Treatment. Butterworth: Woburn, MA; 1991:105-22.

  33. Kondziolka D. Functional radiosurgery. Neurosurgery. Jan 1999;44(1):12-20; discussion 20-2. [Medline].

  34. Rose FC. Trigeminal neuralgia. Arch Neurol. Sep 1999;56(9):1163-4. [Medline].

  35. Truini A, Galeotti F, Cruccu G. New insight into trigeminal neuralgia. J Headache Pain. Sep 2005;6(4):237-9. [Medline].

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Further Reading

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Keywords

trigeminal neuralgia, trigeminal nerve, headache, neuralgia, paroxysmal headache pain, tic douloureux, neuropathic pain, microvascular decompression, Jannetta procedure

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Contributor Information and Disclosures

Author

Marc E Lenaerts, MD, FAHS, Staff Neurologist, Mercy Medical Group, Sacramento, CA; Associate Clinical Professor of Neurology, Department of Neurology, University of California at Davis, Sacramento
Marc E Lenaerts, MD, FAHS is a member of the following medical societies: American Academy of Neurology, American Headache Society, and International Headache Society
Disclosure: Nothing to disclose.

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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